Achieving the MDGs in the Middle East: Why Improved Reproductive Health is Key

(September 2005) Improving women’s reproductive health is crucial to achieving nearly all of the Millennium Development Goals (MDGs)—the global development framework adopted by the United Nations in 2000 for improving people’s lives and combating poverty in a sustained and sustainable way by 2015.

But investing in women’s reproductive health often does not make it to the top of national priorities, for reasons ranging from competing national economic and social issues to cultural sensitivities surrounding sexual and women’s issues. This lack of attention is counterproductive. Making women’s reproductive health a national priority would help accelerate progress toward MDGs across the world—particularly in the Middle East and North Africa (MENA), where overall progress toward attaining the goals is mixed at best and where unmet need for quality family planning and reproductive health care remains high.

Below are brief assessments of how MENA countries are progressing toward some of the MDGs, followed by how improving women’s reproductive health in these countries could improve those performances.

MDG 1: Eradicate Extreme Poverty and Hunger

Despite significant poverty reduction in the past across the region, poverty seems to be entrenched in the MENA region. The overall poverty rate there has not improved since 1990 (the benchmark against which progress toward the MDGs is measured), and 23 percent of people live on less than $2 a day.1 The percentage in poverty is the highest in Yemen, where 45 percent of the population lives on less than $2 a day.2 Poverty also affects nutrition—for instance, more than 20 percent of Egyptians in 2003 were not able to afford the minimum daily calorie intake considered necessary for basic health.3

MDG 2: Achieve Universal Primary Education

The average net enrollment ratio for primary education in the MENA region is about 85 percent, and some MENA countries (such as Algeria and Jordan) are on track to achieve this goal. Literacy among 15 to 24 years olds (also an MDG indicator) ranges from 68 percent in Yemen to 99 percent in Jordan.4

But literacy remains low in some MENA countries, especially for poor women. In Egypt, 91 percent of women ages 15 to 49 in the richest one-fifth of the population had completed five years of primary schooling, compared with only 22 percent of the poorest one-fifth. In such situations, the cycle of illiteracy, high fertility, and poverty continues.

MDG 3:Promote Gender Equality and Women’s Empowerment

The gender gap in education has been narrowing through all educational levels and throughout the MENA region. But Yemen, Morocco, and Egypt have had difficulty closing their literacy gaps between women and men: While 84 percent of Yemeni males between the ages of 15 and 24 can read, for instance, only 51 percent of Yemeni women can. In these three countries together, there are nearly 5 million illiterate women between ages 15 and 24 who are going to marry soon and have children.

MDG 5: Improve Maternal Health

Maternal health has improved at least somewhat in almost all MENA countries, but it remains a key health challenge in parts of the region. Algeria, Iraq, and Syria are expected to miss this MDG, which calls for reducing maternal mortality rates by three-quarters between 1990 and 2015.

And even in countries such as Jordan and Saudi Arabia, which have almost or already met the target, there is much more need for improving maternal health. Maternal deaths are estimated at more than 40 per 100,000 live births in Jordan and more than 20 per 100,000 live births in Saudi Arabia—both far higher than the average for developed countries of 14 deaths per 100,000 births.5

MDG 6: Combat HIV/AIDS, Malaria, and Other Diseases

While the MENA region has the lowest regional rate of HIV infection in the world, infection rates are growing in every MENA country, and there is ample potential in a number of countries for rapid spread of the disease. The vast majority of reported AIDS cases in the MENA region are attributed to injecting-drug use, which creates the potential for spreading HIV to sex workers and the general public. One study in Iran has suggested that one-half of injecting-drug users in the country are married and that one-third have extramarital sex.

Sex workers in the region also appear to be poorly equipped to handle the threat of HIV infection. For instance, while almost all of the sex workers who participated in a study in Kermanshah (a city in western Iran) knew about condoms, only 50 percent said that they had ever used condoms with their clients.6

MDG 7: Ensure Environmental Sustainability

The MENA region is the most arid in the world, and the issue of freshwater scarcity tops the list of the region’s environmental concerns. Population growth has meant that available fresh water in most MENA countries now averages 1,500 cubic meters per capita per year, well below the international threshold of 1,700 cubic meters per capita per year that defines “water-stressed” countries.

Only three countries (Iran, Iraq, and Turkey) hold two-thirds of available freshwater resources in the region, which exacerbates the scarcity. Oil-rich Gulf states such as Kuwait (the most water-scarce country in the world) are heavily dependent on expensive technologies like desalinization to meet their increasing demand—a strategy not available to Yemen, a resource-poor country faced with severe water shortage.

How Increased Investment in Women’s Reproductive Health Will Help

Although there is considerable variation in the region, MENA countries continue to face major challenges to meeting their family planning and reproductive health care needs, including the poor quality of health services, widespread ignorance about reproductive health issues, and continuing gender inequality. Contraceptive use ranges from 74 percent in Iran to 23 percent in Yemen (see figure). Rural women generally having a greater need for accessing quality health services than urban women.

Contraceptive Use and Total Fertility Rates in the MENA Region, 2004

Source: Population Reference Bureau, 2005 World Population Data Sheet (2005).

Improved reproductive health is not only a basic human right for women in MENA countries, but would also move those countries closer to achieving the MDGs. Below are some specific examples:

Helping families avoid unintended pregnancies and promoting small family-size norms would slow population growth and reduce pressure on MENA’s fragile natural resources, particularly its freshwater resources. Providing rural people with universal access to reproductive health care and family planning would also reduce rural-to-urban migration (a driver of natural-resource degradation).

Universal access to reproductive health care—including family planning, care in pregnancy and during and after childbirth, and emergency obstetric care—is essential to improving maternal health. Such access would reduce unwanted pregnancies (which, in turn, would decrease a woman’s lifetime risk of maternal death and illness) as well as reduce the number of unsafe abortions.

Contraception also allows mothers more time to breastfeed between births and reduces their risk of anemia—a condition common throughout the MENA region and one that contributes to maternal illness and death.

Women now constitute about one-half of people who are HIV-positive in the region, and sexual contact is increasingly becoming the main way the virus is spread in MENA countries. Because male and female condoms are the only contraceptive methods that help prevent the transmission of HIV, universal access to reproductive health information and services is critical in the fight against the disease.

Removing economic and social barriers to contraceptive use and reproductive health care would enhance poor people’s health and break the repetitive cycle of the so-called “demographically related poverty trap”—in which families with higher numbers of children tend to be poor and poor families tend to have larger numbers of children. Improved women’s reproductive health and lower fertility also leads to slower population growth and fewer dependents, opening a “demographic window” of opportunity for economic growth at both household and national levels that could lead to poverty reduction.

Ensuring women’s ability to choose the number and timing of their births is key to empowering them as individuals, mothers, and citizens. Overcoming cultural barriers (such as particular or general objections to methods of modern contraception) that limit women’s ability to make these choices are necessary to these women’s wider social, economic, and political participation.

Improved reproductive health for women is crucial to improving education levels for both women and children. Such investment leads to smaller family size, which leaves more resources available per child within families and at the national level. Girls of smaller families are also less likely to be pulled out of school to care for their siblings or to do household chores.7 In turn, educated women generally have healthier children, want smaller families, and make better use of reproductive-health and family planning information and services in achieving their desired family size.

Farzaneh Roudi is the program director for the Middle East and North Africa Project at PRB.

References

World Bank, “Millennium Development Goals: Middle East and North Africa,” accessed online at http://ddp-ext.worldbank.org, on Aug. 2, 2005.

United Nations Development Programme (UNDP), 2004 Human Development Report: Cultural Liberty in Today’s Diverse World (UNDP: New York, 2004): 147-9; and World Bank, “Millennium Development Goals: Middle East and North Africa.”

Stan Bernstein and Emily White, “The Relevance of the ICPD Programme of Action for the Achievement of the Millennium Development Goals—Or Vice Versa: Shared Visions and Common Goals” (New York: UNFPA, 2005), accessed online at www.unfpa.org, on Aug. 31, 2005.